More access to after-hours care linked to less ED use

When patients have access to after-hours services with their primary care provider, emergency room usage is significantly lower and fewer patients go without needed medical care, according to a study by the Center for Studying Health System Change (HSC) released last week by Health Affairs.

The study, which was funded by the National Institute for Health Care Reform, is the first to use a nationally representative sample to describe the U.S. population’s access to after-hours care through their primary care office.

Ann S. O’Malley, MD, HSC senior fellow and author of the study, analyzed data from HSC’s 2010 Health Tracking Household Survey, which included responses from 9,577 patients with a usual primary care source. Of those 9,577 patients, 40.2 percent reported that their providers' practice offered after-hours (evening and weekend) office visits, and 1,470 reported trying to contact their primary care practice after hours in the previous 12 months. Of the 1,470 people who tried to contact their practice, 20.8 percent reported it was “very difficult” or “somewhat difficult” to reach a clinician after hours.

O’Malley found that 30.4 percent of patients with after-hours access to their primary care providers reported emergency room use, compared to 37.7 percent of those lacking after-hours access. She also found that patients with access to after-hours care reported a significantly lower rate of unmet medical need: 6.1 percent versus 13.7 percent of those lacking after-hours access.

“We found that practices that took an approach to approving access to care with some form of after-hours care, whether it be in-house, by phone, or agreements with urgent care centers, really made a huge difference in their continuity of care and avoiding unnecessary emergency department visits,” said O’Malley.

While it’s often “unrealistic” to expect primary care offices to always offer after-hours care for their patients, she said, many practices are coming up with arrangements so there’s some consistent form of contact with clinicians after hours. Those arrangements include a process by which all information collected about patient care after hours is related back to the primary care physician. O’Malley also noted that offering some sort of after-hours care is becoming a trend with patient-centered medical homes, the bundled payment movement and many practices.

According to the study, overall, 29 percent of U.S. primary care physicians offered after-hours care, a far smaller proportion than in other Western industrialized nations. For example, 95 percent of primary care offices in the United Kingdom offer after-hours care and 94 percent do in the Netherlands.

O’Malley also found that of those trying to access after-hours care, children (through a parent or other adult) had the highest rate of contacting their provider. Less healthy adults and those lacking private insurance, reported more difficulty accessing their provider after hours than other respondents.

O’Malley noted that primary care offices often don’t receive enough in reimbursement payments from Medicare and Medicaid, which could be part of the reason many don’t offer after-hours care.

“Right now, many offices just don’t get enough in reimbursements and that needs to be considered when it comes to our country’s payment system,” she said. “Patients being cared for in the right settings with less unnecessary emergency department use will translate into savings and decrease our costs.”

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